Field of the Invention
The present invention relates to the computer field, particularly to the field of semantic network and artificial intelligence, and more particularly to a method and system for automatically evaluating the quality of a medical record.
Description of Related Art
A medical record is a systematic documentation of a patient's medical and care history. Medical record drafting refers to the behavior of a health care provider obtaining related material by medical activities such as interrogation, physical examination, auxiliary examination, diagnosis, treatment and nursing, and forming medial activities documentation through induction, analysis and collation of the material. Medical records play an important role in medical activities.
The information contained in a medical record enables health care providers to provide continuous care to the patient. A medical record also serves as a basis for planning the patient's care, documenting communications between the health care provider and other health professionals contributing to the patient's care, assisting in protecting the legal interests of the patient and health care providers responsible for the patient's care. In addition, medical records can also serve as documents to educate medical students/resident physicians, to provide data for hospital internal auditing and quality assurance, and to provide data for medical research. So the quality of medical records drafted by health care providers is very important.
In current medical practices, precision and completeness of a medical record are two most important criteria for evaluating the quality of the medical record, and are also the most principal quality issues in the drafting of a medical record. Precision and completeness of a medical record have the meanings which follow.
For a certain section of a medical record with a given type, the statements should be complete. For example, the physical examination content of a clinic medical record should include body temperature, respiration and sphygmus. The statements should be as specific as possible. For example, it should be “having had a fever for 3 days” instead of “having a fever.” The statements should be in a certain sequence. For example, the correct sequence of physical examination is temperature, sphygmus and respiration.
Correct terms should be used. For example, a symptom statement should be used in a chief complaint instead of a disease class as far as possible, such as “chief complaint: having had a fever for 3 days” instead of “chief complaint: upper respiratory tract infection.” Formal vocabulary should be used, such as “diarrhea” instead of “having loose bowels.”
In current medical practices, the evaluation of the quality of a medical record is performed by an evaluation person through human judgment based on formulated evaluation criteria for the quality of a medical record. Not only this kind of human judgment method need to consume a lot of time and manpower, but also it is difficult for the method to provide an objective and precise evaluation for the quality of a medical record. In addition, the human judgment method is mainly used for checking the completeness of a medical record and is difficult to be applied to check the precision of a medical record.
Thus, in the art there exists a demand for a method and system for automatically evaluating the quality of a medical record by using a computer.